Although amputations do not increase overall survival in soft tissue sarcoma of the extremity compared with limb salvage surgery, amputation can provide improved local control and symptomatic treatment in patients who might not be candidates for limb salvage surgery, according to study results published in the European Journal of Surgical Oncology.

“We saw a series of patients who had to undergo amputation as opposed to limb salvage surgery for treatment of their soft tissue sarcoma. While limb salvage surgery rates are about 95% for soft tissue sarcoma, amputations are far less common,” Ginger E. Holt, MD, of the department of orthopedics and rehabilitation at Vanderbilt University Medical Centre, told O&P Business News. “The question arose as to whether patients’ overall survival was different between those who needed amputations vs. those treated with limb salvage surgery. In other words, were we changing a patient’s lifespan by amputating their limbs and causing the psychological and physical problems that accompany this surgery?”

Limb salvage vs. amputation

From January 2000 to December 2006, researchers assessed 278 patients with soft tissue sarcoma, 18 of whom underwent amputation for extremity soft tissue sarcoma (STS) either as a definitive or palliative treatment. The 18 patients who underwent amputation were compared with the remaining 260 patients who underwent limb salvage surgery. Main outcome measure included local recurrence, distant metastasis and death due to sarcoma.

For the main outcome measures, 17% of patients died due to sarcoma and 28% died due to other causes not related to their STS. Sixty-seven percent of patients did not develop distant metastasis after amputation and 89% did not develop a local recurrence, according to study results. Overall, researchers found no statistically significant difference between patients undergoing amputation and those undergoing limb salvage surgery when comparing prognostic effects mainly due to sarcoma, distant metastasis and recurrence.

“The decision to undergo amputation as a treatment for STS in the era of limb salvage surgery is one that should be made in a multispecialty tumor center,” the researchers wrote. “Amputation only offers a marginal advantage in local recurrence due to the increasing radical nature of excisions performed in limb salvage surgeries today. There is no benefit with distant metastasis and disease-specific survival with amputation. The functionality of the limb following excision, the tumor characteristics and the extent of neurovascular involvement are just some of the few things to consider in recommending between limb salvage surgery and amputation. Ultimately, the choice lies with the patient following a thorough discussion of all the options available including amputation and reconstruction following limb salvage surgery.”

Future research

To continue to improve overall survival of patients with STS, Holt and colleagues realized that they needed to understand the 
biology of STS, as well as the need for better chemotherapy agents. By performing studies that assess how sarcomas metastasize and progress by proteomic profiling, they hope to determine if categorizing patients as having a highly metastatic or low metastatic potential will allow for specific chemotherapy agents as well as provide chemotherapy targets.

According to Holt, the overall biology of STS still trumps much of what physicians do.

“For the practicing clinician, the results of this study are important for patients and counseling patients. It is important that patients understand that we may or may not change their outcome despite removing a limb. It is important that we set the appropriate expectations as we discuss this with patients,” Holt said. “It is also important that clinicians understand when an amputation is appropriate, when we may be able to save someone’s life or when the biology of the tumor may overcome anything that we do.” — by Casey Murphy

For more information:
Alamanda VK. EJSO. 2012;38:1178-1183.

Disclosure: Holt has no relevant financial disclosures.

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